Chocolate and Heart Health

Educational Objectives

The goals of this program are to improve patient outcomes and satisfaction with health care through principles of integrative medicine, and review potential health benefits of eating chocolate. After hearing and assimilating this program, the clinician will be better able to:

1. Explain the antioxidant effects of chocolate.

Summary

History: cocoa — bean first grown by Mayans and later by Aztecs; used as currency, as medicine, and for religious ceremonies; brought to Spain in 1528; chocolate — first store established in 1657; first available in United States in 1800s; became popular during World War I as part of rations for servicemen (resists spoilage)

Antioxidant compounds in chocolate: flavonoids — several types exist; micronutrients derived from plants; also found in extra-virgin olive oil, red wine, tea, apples, onions, and blueberries; flavonols — class of flavonoids abundant in chocolate; examples include catechin and epicatechin; found in tea, red wine, beans, grapes, apricots, and cherries; catechin — flavan-3-ol; cocoa richest source; 3-ring structure has antioxidant effects (stabilizes free radicals through rapid transfer of electrons; scavenges and eliminates free radicals by donating hydrogen atom); in vitro antioxidant effects of catechin — also seen with epicatechin; augments release of nitric oxide from endothelium; decreases leukotrienes and increases prostacyclins; reduces low-density lipoprotein (LDL) cholesterol; suppresses platelet reactivity

Studies of effects of cocoa: meta-analysis of small trials — cocoa significantly lowered LDL cholesterol (by 6 mg/dL); positive effect on endothelial function seen within 2 hr and ≤18 wk of dose; lowers insulin resistance and fasting insulin; significantly reduces BP (≈3 mm Hg); white vs dark chocolate — white chocolate does not contain cocoa; presence of milk only difference between dark and milk chocolate; typical Hershey’s special dark chocolate bar 25% to 30% cocoa; dark chocolate does not mean higher cocoa content; study — adults with stage 1 hypertension given 6.3 g/day of dark vs white chocolate; dose-response effect seen over time; significant reductions found in systolic and diastolic BP (≈3 mm Hg); levels of catechin and epicatechin in blood found to increase over time; no significant increase seen in nitric oxide production; nitric oxide bioactivity increased significantly at 18 wk (as measured by S-nitrosoglutathione), which indicated long-term beneficial effect on vascular production

Clinical events: low doses of chocolate improve cardiovascular risk factors; long-term trials of clinical events not yet undertaken; handful of observational studies show varied outcomes; meta-analysis — showed risk for any cardiovascular disease significantly lowered among those who frequently consume cocoa or chocolate; association with heart failure not significant, but significant inverse association with stroke observed

Summary: effects of cocoa — most specific for vascular health; effects on lipids and platelet reactivity also seen; observed at low doses; greater intake associated with lower risk for cardiovascular disease events; potential for publication bias possible; majority of flavonoids destroyed in highly processed and commercialized chocolate products; small square of dark chocolate containing 65% cocoa recommended daily; evidence supports benefits for brain health

Acknowledgments

Dr. Rakel was recorded at the 2014 Primary Care Conference, held November 13-14, 2014, in Madison, WI, and sponsored by the University of Wisconsin School of Medicine and Public Health and the University of Wisconsin–Madison School of Nursing. For information about upcoming CME activities from the University of Wisconsin School of Medicine and Public Health, please visit www.ocpd.wisc.edu. Dr. Mozaffarian was recorded at the 12th Annual Cardiovascular Disease Prevention International Symposium, held February 6-9, 2014, in Miami, FL, and sponsored by Baptist Health South Florida. For information about upcoming CME activities from Baptist Health South Florida, please visit www.cme.baptisthealth.net. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Suggested Readings

Bauer BA et al: Clinical pearls in complementary and integrative medicine (CIM). Dis Mon, 2014 Jul;60(7):323-31; Glick RM et al: Integrative medicine. Depression. FP Essent, 2013 Mar;406:13-7, 34-40; quiz 41-6; Hilbers J, Lewis C: Complementary health therapies: moving towards an integrated health model. Collegian, 2013;20(1):51-60; Jong MC et al: Integration of complementary and alternative medicine in primary care: what do patients want? Patient Educ Couns, 2012 Dec;89(3):417-22; Lloyd DP et al: Integrative medicine improves mood in an inpatient setting. Psychiatr Serv, 2012 Nov;63(11):1154-5; Wolever RQ et al: Patients seek integrative medicine for preventive approach to optimize health. Explore (NY), 2012 Nov-Dec;8(6):348-52; Flammer AJ et al: Cardiovascular effects of flavanol-rich chocolate in patients with heart failure. Eur Heart J, 2012 Sep;33(17):2172-80; Heiss C, Kelm M: Chocolate consumption, blood pressure, and cardiovascular risk. Eur Heart J, 2010 Jul;31(13):1554-6; Larsson SC et al: Chocolate consumption and risk of stroke: a prospective cohort of men and meta-analysis. Neurology, 2012 Sep 18;79(12):1223-9; Ried K et al: Effect of cocoa on blood pressure. Cochrane Database Syst Rev, 2012 Aug 15;8:CD008893; Zhang Z et al: Chocolate intake reduces risk of cardiovascular disease: evidence from 10 observational studies. Int J Cardiol, 2013 Oct 15;168(6):5448-50; Chon TY, Lee MC: Acupuncture. Mayo Clin Proc, 2013 Oct;88(10):1141-6.

Readings

Suggested Readings

Bauer BA et al: Clinical pearls in complementary and integrative medicine (CIM). Dis Mon, 2014 Jul;60(7):323-31; Glick RM et al: Integrative medicine. Depression. FP Essent, 2013 Mar;406:13-7, 34-40; quiz 41-6; Hilbers J, Lewis C: Complementary health therapies: moving towards an integrated health model. Collegian, 2013;20(1):51-60; Jong MC et al: Integration of complementary and alternative medicine in primary care: what do patients want? Patient Educ Couns, 2012 Dec;89(3):417-22; Lloyd DP et al: Integrative medicine improves mood in an inpatient setting. Psychiatr Serv, 2012 Nov;63(11):1154-5; Wolever RQ et al: Patients seek integrative medicine for preventive approach to optimize health. Explore (NY), 2012 Nov-Dec;8(6):348-52; Flammer AJ et al: Cardiovascular effects of flavanol-rich chocolate in patients with heart failure. Eur Heart J, 2012 Sep;33(17):2172-80; Heiss C, Kelm M: Chocolate consumption, blood pressure, and cardiovascular risk. Eur Heart J, 2010 Jul;31(13):1554-6; Larsson SC et al: Chocolate consumption and risk of stroke: a prospective cohort of men and meta-analysis. Neurology, 2012 Sep 18;79(12):1223-9; Ried K et al: Effect of cocoa on blood pressure. Cochrane Database Syst Rev, 2012 Aug 15;8:CD008893; Zhang Z et al: Chocolate intake reduces risk of cardiovascular disease: evidence from 10 observational studies. Int J Cardiol, 2013 Oct 15;168(6):5448-50; Chon TY, Lee MC: Acupuncture. Mayo Clin Proc, 2013 Oct;88(10):1141-6.

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Mozaffarian is a consultant for FoodMinds and McKinsey & Company; receives grant/research support from GlaxoSmithKline, Pronova BioPharma ASA, and Sigma-Tau Pharmaceuticals; and is on the scientific advisory board for Unilever. The planning committee reported nothing to disclose.

Acknowledgements

Dr. Mozaffarian was recorded at the 12th Annual Cardiovascular Disease Prevention International Symposium, held February 6-9, 2014, in Miami, FL, and sponsored by Baptist Health South Florida. For information about upcoming CME activities from Baptist Health South Florida, please visit www.cme.baptisthealth.net. The Audio Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

IM621002

Qualifies for:

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.